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When assessing a patient with generalized anxiety disorder (GAD), which symptom would a nurse most likely observe?
- A. Flashbacks
- B. Excessive worry
- C. Hallucinations
- D. Compulsive behaviors
Correct Answer: B
Rationale: Excessive worry is a primary characteristic of generalized anxiety disorder (GAD). Patients with GAD experience persistent and excessive worry about various aspects of their lives, often anticipating disaster or catastrophic outcomes. This worry is difficult to control and can be accompanied by physical symptoms like restlessness, fatigue, irritability, muscle tension, and difficulty concentrating. Flashbacks are more commonly associated with post-traumatic stress disorder (PTSD), hallucinations are more typical of psychotic disorders, and compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD). Therefore, when assessing a patient with GAD, a nurse would most likely observe excessive worry.
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A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms should the nurse expect to observe during withdrawal? Select one that doesn't apply.
- A. Tremors
- B. Hallucinations
- C. Diaphoresis
- D. Bradycardia
Correct Answer: D
Rationale: During alcohol withdrawal, symptoms such as tremors, hallucinations, diaphoresis, and seizures are commonly observed. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia, an increased heart rate, is more commonly seen. Therefore, bradycardia is the correct answer as it is not an expected symptom during alcohol withdrawal. Tremors, hallucinations, and diaphoresis are all common manifestations of alcohol withdrawal, while bradycardia is not typically seen in this context.
When developing a care plan for a client with generalized anxiety disorder (GAD), which of the following interventions should not be included?
- A. Encourage the client to avoid anxiety-provoking situations.
- B. Teach the client relaxation techniques.
- C. Encourage the client to express their feelings.
- D. Provide a structured daily routine.
Correct Answer: A
Rationale: Avoiding anxiety-provoking situations is not a recommended intervention in caring for a client with generalized anxiety disorder (GAD) as it can reinforce the client's anxiety. Exposing the client gradually to feared situations can help reduce anxiety in the long term through techniques like cognitive-behavioral therapy. Teaching relaxation techniques helps the client manage stress and anxiety effectively. Encouraging the client to express their feelings promotes emotional processing and reduces internal tension. Providing a structured daily routine can offer predictability and stability, which are beneficial for individuals with GAD.
During an assessment, a client is demonstrating symptoms of moderate anxiety. Which of the following symptoms would be indicative of moderate anxiety?
- A. Fidgeting
- B. Laughing inappropriately
- C. Palpitations
- D. Nail biting
Correct Answer: C
Rationale: Palpitations are a common physical symptom seen in clients experiencing moderate anxiety. Fidgeting, laughing inappropriately, and nail biting can also indicate heightened stress levels. It's important for healthcare providers to recognize these signs and provide appropriate support. While anxiety can manifest in various ways, other indicators of moderate anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbance. It's crucial for healthcare providers to assess these symptoms to provide effective care and interventions. Laughing inappropriately and nail biting are more commonly associated with nervousness or social discomfort, while fidgeting may signal mild anxiety.
According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?
- A. A client rudely complaining about limited visiting hours
- B. A client exhibiting aggressive behavior toward another client
- C. A client stating that no one cares
- D. A client verbalizing feelings of failure
Correct Answer: B
Rationale: The correct answer is B. According to Maslow's hierarchy of needs, safety needs are considered fundamental and must be addressed before higher-level needs. When a client exhibits aggressive behavior toward another client, it poses an immediate threat to safety and requires priority intervention by the nurse to ensure the well-being of all individuals involved. Clients who are rude in their complaints (Choice A), express feelings of failure (Choice D), or state that no one cares (Choice C) are addressing higher-level needs related to social interactions, esteem, and self-actualization, respectively, which can be addressed once safety needs are secured.
Which symptom should a healthcare provider identify as typical of the fight-or-flight response?
- A. Pupil dilation
- B. Increased heart rate
- C. Decreased salivation
- D. Decreased peristalsis
Correct Answer: B
Rationale: The correct answer is B: Increased heart rate. During the fight-or-flight response, the sympathetic nervous system is activated, causing the release of epinephrine. This hormone triggers an increase in heart rate to supply more blood to the muscles for a rapid response. Pupil dilation occurs to enhance vision in preparation for quick reactions. On the other hand, salivation and peristalsis decrease as the body prioritizes functions necessary for immediate action rather than digestion-related activities. Therefore, choices A, C, and D are incorrect as they do not align with the typical physiological changes associated with the fight-or-flight response.